LAUSR

We must first thank Dr Çağıcı for his kind comment1 on our article,2 but also for his very relevant questions. It is exciting for us that the advantages of piezosurgery appear to be spreading throughout the rhinoplasty world. We began to work with the Variosurg device (NSK, Nakanishi, Inc., Tochigi, Japan) in March 20132 using maxillo-facial inserts to become familiar with this new technology in cadavers. Dr Gerbault then designed a set of inserts for rhinoplasty. Those inserts were initially less efficient and generated too much heat. Shortly thereafter, a prototype of a new control unit, the VarioSurg3 Med, became available for clinical study. This was the first NSK module that was compatible for clinical use in the operating room, and thus our experience began using rhinoplasty inserts with piezosurgery. Dr Ilhan’s article3 comments on the use of a dental module for rhinoplasty, while we have been using a medical module in our operating room. Certainly the VarioSurg works for rhinoplasty, but the only inserts available are maxillo-facial and the use of this dental device is not “approved.”4 We moved to Acteon-Comeg instruments in 2014 for one main reason. The researchers needed to standardize our clinical work and results between Paris (O.G.) and Newport Beach (R.K.D. and A.K.). NSK did not have a unit in the United States that was approved by the Food and Drug Administration (FDA). However, Acteon-Comeg was provided by Synthes in the United States with FDA clearance. Thus, by switching to Acteon-Comeg we were able to use the same machines in both France and the United States. The second question posed by Dr Çağıcı is important and impacts the sequence and design of osteotomies using piezosurgery after an extended, open approach. It is important to remember that this is very different from the initial experience described by Robiony, where external osteotomies were done without an extended bony dissection.5,6 We define bony instability when you apply pressure to the bone and it does not come back to its initial position. This may create a step between fracture lines, palpability, visibility, and asymmetry. With our extended, open approach the whole bony surface has been undermined. We still believe that bone support relies on intrinsic and extrinsic factors: completeness of the fracture, thickness and stiffness of bones, extent of bone mobilization, integrity of the mucoperiosteal sheet, integrity of the bony cartilaginous attachments in the keystone areas, and the underlapping extent of the upper lateral cartilage beneath the bones. In conclusion, Dr Ilhan’s article is a great contribution to the validation of the use of piezoelectric instruments for rhinoplasty, especially concerning the postoperative outcomes. However, like every new technique, especially when a there is also a significant modification of the access and undermining, care must be taken to mention the potential issues if specific instruments are not accurately used or if technical details concerning osteotomies/osteoplasties are not accurately followed. Since the first presentations of the use of piezoelectric instruments through an extended open approach in 2014, and the publication of the articles in this journal, several publications